Available online http://ccforum.com/content/13/3/148Page 1 of 2 page number not for citation purposes Abstract Catheter-related bloodstream infection is one of the most serious complicat
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Page 1 of 2
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Abstract
Catheter-related bloodstream infection is one of the most serious
complications of central venous access devices
Antimicrobial-coated catheters represent one novel strategy to prevent
catheter-related bloodstream infection A comprehensive economic
evaluation is essential to guide informed decision-making regarding
the adoption of this technology and its expected benefits in
healthcare institutions
‘Doubt is not a pleasant condition, but certainty is absurd.’
(Voltaire)
In the previous issue of Critical Care, Halton and colleagues
provided a comprehensive cost-effectiveness analysis
com-paring antimicrobial catheters with uncoated catheters for
prevention of catheter-related bloodstream infection (BSI) in
the intensive care unit [1]
Central venous access is essential in critically ill neonates
requiring parenteral alimentation and in children and adults
requiring intensive cancer chemotherapy, bone marrow or
solid organ transplants, home antibiotic therapy, hemodialysis
or total parenteral nutrition [2,3] Upwards of 5 million US
patients require prolonged central venous access each year
[4,5] Although reliable, these devices are nonetheless
associated with a considerable risk of catheter-related BSI,
with approximately 80,000 catheter-related BSIs occurring in
the United States annually While mortality attributable to
catheter-related BSI is uncertain because of conflicting
findings from studies [6-9], there is no doubt that
catheter-related BSI causes an increased length of stay and increased
healthcare costs Since October 2008 the Centers for
Medicare and Medicaid have ceased to reimburse healthcare
institutions for catheter-related BSI, now increasingly recognized as a preventable complication of healthcare Several effective strategies for preventing catheter-related BSI have emerged in recent years [10] These strategies include chlorhexidine rather than povidone–iodine for cuta-neous antisepsis, maximal barrier precautions, use of a checklist to guide insertion and maintenance, preferential use
of the subclavian vein rather than the femoral or internal jugular vein for insertion and the use of antimicrobial-coated catheters Several types of antimicrobial-coated catheters exist, including chlorhexidine–sulfadiazine-impregnated cathe-ters, minocycline–rifampin-impregnated catheters and silver platinum–carbon-impregnated catheters
Although the efficacy of antimicrobial-coated catheters compared with uncoated catheters for reducing BSI has been demonstrated in several randomized controlled trials, syste-matic reviews and meta-analyses [11], the decision to adopt these catheters is complex because of the increased cost relative to uncoated catheters, uncertainty regarding the magnitude of adverse consequences of catheter-related BSI, and the relative efficacy of the various types of antimicrobial catheters As a result, it is not surprising that, in a recent survey
of hospitals, Krein and colleagues found only 32% of Veterans Affairs hospitals and 38% of non-Veterans Affairs hospitals reported using antimicrobial-impregnated catheters [12] The most recent Centers for Disease Control and Prevention recommendations for prevention of catheter-related BSI state that: ‘antimicrobial or antiseptic-impregnated CVC [central venous catheters] should be used in adults whose catheter is expected to remain in place >5 days if, after implementing a comprehensive strategy to reduce rates of catheter-related BSI, the rate remains above the goal set by the individual
Commentary
Antimicrobial catheters in the ICU: is the juice worth the
squeeze?
Nasia Safdar
Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, H4/572, 600 Highland Avenue, Madison, WI 53792, USA
Corresponding author: Nasia Safdar, ns2@medicine.wisc.edu
This article is online at http://ccforum.com/content/13/3/148
© 2009 BioMed Central Ltd
See related research by Halton et al., http://ccforum.com/content/13/2/R35
BSI = bloodstream infection
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institution based on benchmark rates and local factors The
comprehensive strategy should include the following three
components: educating persons who insert and maintain
catheters, use of maximal sterile barrier precautions, and a
2% chlorhexidine preparation for skin antisepsis during CVC
insertion (category IB)’ [13]
With rising costs of healthcare and increasingly constrained
resources, the need for assessment of clinical and economic
outcomes of a novel intervention is readily apparent While
other cost-effectiveness analyses of antimicrobial catheters
have been reported, many studies have methodologic issues
limiting internal validity and, in many cases, external validity
These issues were summarized in a recent review by the
authors of the present study [14,15] Halton and colleagues
are to be commended for their careful consideration of
esti-mates of costs, effectiveness and the exploration of
un-certainty, all critical elements of a cost-effectiveness analysis
Because the results of cost-effectiveness analyses are very
sensitive to the choice of inputs, the source of the estimates
should be clearly outlined, as has been done for this study
The authors chose a broad healthcare perspective for this
study, expressed health outcomes in quality-adjusted life
years and used detailed previously published costing studies
to obtain costs [1] Key assumptions of the base-case
scenario included an overall incidence of catheter-related BSI
of 2.5%, a 1.06 relative risk of catheter-related BSI mortality,
and an excess length of stay of 2.4 intensive care unit days
and 7.5 general ward days Extensive sensitivity analyses
were undertaken varying several parameters to explore
un-certainty Overall the authors found that the minocycline–
rifampin-coated catheters dominated the other types of
catheters Fifteen infections could be avoided compared with
the uncoated catheters, and 1.6 quality-adjusted life years
per 1,000 catheters placed were generated The cost saving
realized with this approach was AUS$130,000 per 1,000
catheters There was, however, considerable uncertainty
especially when attributable mortality was considered to be
low and the baseline infection rates were low
The findings of Halton and colleagues’ study should be
inter-preted in the context of its limitations [1] The authors
assumed that infection control practices were optimal in the
intensive care unit, the causative microorganism was not
taken into account when obtaining costs, and additional
interventions that are commonly part of catheter
infection-prevention approaches, such as the catheter bundle or
education of healthcare providers, were not compared with
antimicrobial-impregnated catheters
Halton and colleagues add to the growing body of literature
in infection control that incorporates assessments of
economic evaluation to guide optimal allocation of
con-strained resources Ultimately however, institutions must
weigh several factors – including rates of catheter-related
BSI at baseline, costs of treating the infection, the proportion of patients requiring central venous catheters, the duration of catheterization and the use of other preventive measures that may reduce the risk of infection, such as the catheter infection-prevention bundle, to decide whether the juice is worth the squeeze Future research should examine the comparative effectiveness of the impregnated catheters with other measures that have recently been shown to reduce the risk of infection, such as chlorhexidine-impregnated sponge dressings [16]
Competing interests
The author declares that they have no competing interests
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